Nursing NEED ASSIGNMENT COMPLETED BY 8/17/2026. .

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NM701officevisitSOAPtemplate-11.docx

Date and time of simulation:

Patient name:

SUBJECTIVE

CC (Chief Concern): In patient’s own words

HPI: (History of Present Issue)

___ y/o G P (TPAL) reports (OLDCARTS)

Other relevant information

Current medications:

Allergies:

PMH: Past Medical history: (choose pertinent areas)

· Medical:

· Surgical:

· Obstetric Hx:

· GYN Hx:

· Psychiatric Hx:

· Family history:

· Social history:

· Health maintenance (PCP, immunizations, etc.)

ROS: (choose pertinent systems)

OBJECTIVE

· General Survey:

· Vital Signs: Wt, Ht, BMI, BP, HR, RR, Temp (as indicated)

· Targeted Physical Exam:

· In-office Diagnostics:

ASSESSMENT (with ICD-10 codes )

1. Episodic gyn problem= diagnosis (i.e. pelvic pain, contraceptive counseling, confirmation of pregnancy, etc.)

a. Include pertinent differentials

2. Chronic Health problems = diagnosis (optional)

PLAN: ( Note that this Plan is not a Discharge Summary for the patient. Write it focusing on communication with the next clinician, not the patient.)

Treatment:

· Medications & lifestyle changes:

· Diagnostic testing:

· Consultation/Coordination of care:

Patient and family education: (as appropriate)

Follow up:

· RTC ___

Signed:

NM701officevisitSOAPtemplate-11.docx

Date and time of simulation:

Patient name:

SUBJECTIVE

CC (Chief Concern): In patient’s own words

HPI: (History of Present Issue)

___ y/o G P (TPAL) reports (OLDCARTS)

Other relevant information

Current medications:

Allergies:

PMH: Past Medical history: (choose pertinent areas)

· Medical:

· Surgical:

· Obstetric Hx:

· GYN Hx:

· Psychiatric Hx:

· Family history:

· Social history:

· Health maintenance (PCP, immunizations, etc.)

ROS: (choose pertinent systems)

OBJECTIVE

· General Survey:

· Vital Signs: Wt, Ht, BMI, BP, HR, RR, Temp (as indicated)

· Targeted Physical Exam:

· In-office Diagnostics:

ASSESSMENT (with ICD-10 codes )

1. Episodic gyn problem= diagnosis (i.e. pelvic pain, contraceptive counseling, confirmation of pregnancy, etc.)

a. Include pertinent differentials

2. Chronic Health problems = diagnosis (optional)

PLAN: ( Note that this Plan is not a Discharge Summary for the patient. Write it focusing on communication with the next clinician, not the patient.)

Treatment:

· Medications & lifestyle changes:

· Diagnostic testing:

· Consultation/Coordination of care:

Patient and family education: (as appropriate)

Follow up:

· RTC ___

Signed:

NM701officevisitSOAPtemplate-11.docx

Date and time of simulation:

Patient name:

SUBJECTIVE

CC (Chief Concern): In patient’s own words

HPI: (History of Present Issue)

___ y/o G P (TPAL) reports (OLDCARTS)

Other relevant information

Current medications:

Allergies:

PMH: Past Medical history: (choose pertinent areas)

· Medical:

· Surgical:

· Obstetric Hx:

· GYN Hx:

· Psychiatric Hx:

· Family history:

· Social history:

· Health maintenance (PCP, immunizations, etc.)

ROS: (choose pertinent systems)

OBJECTIVE

· General Survey:

· Vital Signs: Wt, Ht, BMI, BP, HR, RR, Temp (as indicated)

· Targeted Physical Exam:

· In-office Diagnostics:

ASSESSMENT (with ICD-10 codes )

1. Episodic gyn problem= diagnosis (i.e. pelvic pain, contraceptive counseling, confirmation of pregnancy, etc.)

a. Include pertinent differentials

2. Chronic Health problems = diagnosis (optional)

PLAN: ( Note that this Plan is not a Discharge Summary for the patient. Write it focusing on communication with the next clinician, not the patient.)

Treatment:

· Medications & lifestyle changes:

· Diagnostic testing:

· Consultation/Coordination of care:

Patient and family education: (as appropriate)

Follow up:

· RTC ___

Signed:

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